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GALL BLADDER

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  1. GALL BLADDER BY DR. HAYDER M. ABDULNABI MD, CABS

  2. ANATOMY PEAR-SHAPED, 7.5-12.5 CM NORMAL CAPACITY- 50 ML FUNDUS, BODY, NECK (TERMINATES IN A NARROW INFUNBIBULUM) ( HARTMANN’S POUCH- A DILATATION IN THE NECK DUE TO AN IMACTED STONE) CRISS-CROSS MUSCLE COAT (WELL DEVELOPED IN THE NECK) GLANDULAR MUCOUS MEMBRANE WITH CRYPTS OF LUSCHA

  3. THE CYSTIC DUCT 2.5 CM (CONTAINS THE SPIRAL VALVE OF HEISTER) THE COMMON HEPATIC DUCT 2.5CM (UNION OF RT AND LT HEPATIC DUCTS) THE COMMON BILE DUCT 7.5CM (JUNCTION OF CHD AND THE CYSTIC DUCT), OF 4 PARTS

  4. 1- SUPRADUODENAL 2.5CM (RUNS IN THE FREE EDGE OF LESSER OMENTUM 2- RETRODUODENAL 3- INFRADUODENAL 4- INTRADUODENAL (PASSES OBLIQUELY THROUGH 2ND PART OF DUODENUM, SURROUNDED BY THE SPHINCTER OF ODDI, OPENS AT THE SUMMIT OF THE PAPILLA OF VATER

  5. THE ARTERIAL SUPPLY OF THE GALL BLADDER THE CYSTIC ARTERY (BRANCH OF THE RT HEPATIC ARTERY), USUALLY BEHIND THE CBD ACCESSORY CYSTIC ARTERY (OCCASIONAL)(BRANCH OF THE GASTRODUODENAL ARTERY)

  6. LYMPHATICS SUBSEROSAL AND SUBMUCOSAL DRAIN INTO THE CYSTIC LYMPH NODE OF LUND (SENTINEL LN) THEN TO THE HILUM OF THE LIVER TO THE COELIAC LYMPH NODES SUBSEROSAL LYMPHATICS CONNECT WITH THE SUBCAPSULAR LYMPHATICS OF THE LIVER (FREQUENT SPREAD OF GALL BLADDER CA TO THE LIVER)

  7. FUNCTIONS OF THE GALL BLADDER BILE IS COMPOSED OF 97% WATER, 1-2% BILE SALTS, 1% PIGMENTS, CHOLESTEROL AND FATTY ACIDS LIVER EXCRETION RATE IS 40 ML/HOUR 1- RESERVOIR (FASTING CAUSE RESISTANCE INCREASE IN SPHINCTER OF ODDI) (FEEDING DECREASE THE RESISTANCE AND THE GALL BLADDER CONTRACTS BY THE ACTION OF CHOLECYSTOKININ RELEASED BY UPPER INTESTINAL MUCOSA IN RESPONSE TO FOOD PARTICULARLY FAT)

  8. 2- CONCENTRATION OF BILE 5-10 TIMES ( BY ACTIVE ABSORBTION OF WATER, SOD. CHLORIDE, AND BICARBONATE) WITH INCREASE IN THE PROPORTION OF BILE SALTS, PIGMENTS, CHOLESTEROL AND CALCIUM 3- MUCIN SECRETION, 20ML/HOUR

  9. INVESTIGATIONS OF THE BILIARY TRACT 1- PLAIN RADIOGRAPH-- (RADIO-OPAQUE STONE 10%, PORCLAIN GALL BLADDER, LIMEY BILE, AIR) 2- ORAL CHOLECYSTOGRAPHY-- (A CONTROL X-RAY IS TAKEN THE DAY BEFORE AND IOPANOIC ACID CONTRAST MEDIUM TABLETS IS TAKEN ORALLY AT NIGHT, THE NEXT DAY ERRECT AND SUPINE X-RAY IS TAKEN TO THE RT HYPOCHONDRIUM AND X-RAY REPEATED TO OBSERVE GALL BLADDER CONTRACTION(

  10. RADIO-OPAQUE STONES PLAIN X- RAY

  11. PLAIN X-RAY PORCLAIN GB

  12. AIR PLAIN X-RAY

  13. ORAL CHOLECYSTOGRAM STONES

  14. NONVISUALIZATION (NONFUNCTIONING) GALL BLADDER IS DUE TO-- FAILURE OF THE PATIENT TO TAKE THE TABLETS, VOMITING, MALABSORBTION, IMPAIRED LIVER FUNCTION, BLOCKED CYSTIC DUCT,SEVERE GALL BLADDER DISEASE (FAILURE OF CONCENTRATION)

  15. 3- INTRAVENOUS CHOLANGIOGRAM– USING INTRAVENOUS RADIO-OPAQUE MEDIUM TO SHOW THE BILE DUCTS, MAY BE USED WITH ORAL CHOLECYSTOGRAM OR TOMOGRAPHY (A METHOD TO PUT ONE GIVEN PLANE INTO SHARP FOCUS WHILE BLURRING OTHERS)

  16. 4- ULTRASONOGRAPHY (NONINVASIVE) AND SHOWS BILIARY CALCULI, DILATION OF BILIARY TREE,CA HEAD PANCREAS, WALL THICKNESS, GALL BLADDER SIZE, HALLO SIGN 5- RADIOISOTOP SCANNING– USING RADIOACTIVE IODINE(131) OR Tc(99) 6- COMPUTED TOMOGRAPHY– IN OBESE OR PATIENTS WITH GASEOUS DISTENTION THAT MAKE ULTRASONOGRAPHY DIFFICULT

  17. GB STONE ACOSTIC SHADOW US

  18. STONE CBD ACOSTIC SHADOW ULTRASONOGRAPHY

  19. 7- ENDOSCOPIC RETROGRADE CHOLAGIOPANCREATOGRAPHY (ERCP)– BY CANNULATION OF THE AMPULLA OF VATER USING FIBEROPTIC DUODENOSCOPE AND INJECTION OF CONTRAST MEDIUM ,TO TAKE SAMPLE FOR CULTURE AND BRUSHING FOR CYTOLOGY. ITS USE CAN BE EXTENDED TO DO PAPILLOTOMY TO EXTRACT STONES, PASSING CATHETER OR DORMIA BASKET, AND STENT PLACING THROUGH STRICTURES. IT MAY CAUSE ASCENDING BILIARY INFECTION, SO SHOULD BE DONE UNDER ANTIBIOTICS COVER

  20. DUCT OF WIRSUNG CATHETER IN THE AMPULLA ERCP

  21. 8- PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY- INJECTION OF CONTRAST MEDIUM THROUGH A CHIBA OR OKUDA NEEDLE (15CM LONG, 0.7MM IN DIAMETER) INTO THE LIVER THROUGH THE 8TH INTERCOSTAL SPACE IN THE MIDAXILLARY LINE. IT CAN BE USED TO PUT A CATHETER FOR DRAINAGE OR STENT FOR ANTEGRADE DRAINAGE. BLEEDING TENDENCY IS A CONTRA INDICATION AND THE PROCDURE SHOULD BE DONE UNDER ANTIBIOTICS COVER

  22. CHIBA NEEDLE PER CUTANEOUS TRANSHEPATIC CHOLANGIOGRAM

  23. 9- PEROPERATIVE CHOLANGIOGRAPHY– BY TAKING X-RAY DURING OPERATION AFTER INJECTING THE CONTRAST BY A POLYTHENE CATHETER INTRODUCED INTO THE CBD THROUGH AN OPENING IN THE CYSTIC DUCT TO DETECT ANY STONE IN THE CBD BEFORE EXPLORATION. FAILURE OF THE CONTRAST TO ENTER THE DUODENUM MAY BE ALSO DUE TO SPHINCTER SPASMAND HERE SUCCINYLCHOLINE IS GIVEN TO EXCLUDE THIS POSSIBILITY 20% OF CASES THE MEDIUM ENTER THE DUCT OF WIRSUNG AND IT IS NOT NECESSARILY PATHOLOGICAL

  24. CATHETER PER- LAPAROSCOPIC CHOLANGIOGRAPHY

  25. CATHETER CBD DUODENUM PER-OPERATIVE CHOLANGIOGRAM

  26. 10- OPERATIVE BILIARY ENDOSCOPY (CHOLEDOCHOSCOPY) 11- PEROPERATIVE POSTEXPLORATORY CHOLANGIOGRAPHY (THROUGH THE T- TUBE) 12- POSTOPERATIVE CHOLANGIOGRAPHY (T-TUBE), 10-14 DAYS AFTER CHOLEDOCHOTOMY

  27. STONE IN CBD PER-OPERATIVECHOLANGIOGRAPH

  28. Rt HEPATIC DUCT Lt HEPATIC DUCT PER-OPERATIVE CHOLEDOCHOSCOPE

  29. STONE IN COMMON HEPATIC DUCT T-TUBE T-TUBE CHOLANGIOGRAM

  30. CONGENITAL ANOMALIES OF THE GALL BLADDER AND BILE DUCTS 1. ANOMALIES OF THE GALL BLADDER- ABSENCE PHRYGIAN CAP (HAT OF THE PEOPLE OF PHRYGIA IN ANCIENT ASIA MINOR) (FRENCH REVOLUTION LIBERTE CAP) FLOATING GALL BLADDER—TORTION DOUBLE GALL BLADDER

  31. 2. ANOMALIES OF THE DUCTS- ABSENCE ATRESIA CONGENITAL DILATATION OF INTRAHEPATIC DUCTS CHOLEDOCHAL CYST LOW INSERTION OF CYSTIC DUCT ACCESSORY CHOLECYSTOHEPATIC DUCT

  32. 3. ANOMALIES OF THE ARTERIES- RT HEPATIC ARTERY AND OR CYSTIC ARTERY CROSS IN FRONT OF THE CHD HEPATIC ARTERY TAKE A TORTOUS COARSE IN FRONT OF THE ORIGIN OF THE CYSTIC DUCT RT HEPATIC ARTERY IS TORTOUS AND THE CYSTIC ARTERY IS SHORT (CATERPILLAR TURN) ACCESSORY CYSTIC ARTERY

  33. GALL STONES(CHOLELITHIASIS) • MIXED STONES- 90%, CHOLESTEROL IS THE MAJOR COMPONENT, Ca CARBONATE, Ca PHOSPHATE, Ca PALMITATE AND PROTEIN (USUALLY MULTIPLE AND FACETED) 2. CHOLESTEROL STONES- (CHOLESTEROL SOLITAIRE) 3. PIGMENT STONES- (SMALL, BLACK, MULTIPLE)

  34. MIXED STONES

  35. MIXED STONES

  36. CHOLESTEROL STONES

  37. PIGMENTSTONES

  38. LIMEY BILE- OCCUR WHEN THERE IS GRADUAL OBSTRUCTION TO THE CYSTIC DUCT OR THE CBD (CHRONIC PANCREATITIS, CA PANCREAS) THE GALL BLADDER WILL BE OPAQUE IN A PLAIN X-RAY (FILLED BY Ca CARBONATE AND Ca PHOSPHATE) WHICH IS THE COMPONENTS OF TOOTH PASTE

  39. CHOLESTEROL IS HELD IN SOLUTION BY THE DETRERGENT EFFECT OF BILE SALTS AND PHOSPHOLIPID (LECITHINE)TO FORM MICELLES. ANY CHANGE IN THE EQUILIBRIUM BETWEEN THESE THREE ELEMENTS WILL LEAD TO GALL STONE FORMATION

  40. HYDROPLYLIC END HYDROPHOBIC END (CHOLESTEROL) BILE SALT MICELLE

  41. PATHOGENESIS OF GALL STONE FORMATION • METABOLIC- INCREASE CHOLESTEROL LEVEL IN BILE(SUPERSATURATED OR LITHOGENIC BILE), WITH AGE, FEMALE ( CONTRCEPTIVE PILLS), OBESITY, PATIENTS ON CLOFIBRATE BILE SALTS DECREASE BY INTERRUPTION OF ENTERO-HEPATIC CIRCULATION( ILEAL DISEASSE, RESECTION, BYPASS SURGERY, CHOLESTYRAMINE) ESTROGEN DECREASE CONCENTRATION OF BILE SALT IN THE BILE(CCP)

  42. CHOLESTEROL SOLUBILITY STATUS

  43. 2. INFECTION- NIDUS 3. BILE STASIS- GALL BLADDER CONTRACTILITY DECREASE IN PREGNANCY, BY ESTROGEN(CCP), AFTER TRUNCAL VAGOTOMY, PATIENTS ON TPN ( LACK OF GOOD ORAL INTAKE) CAUSE DECREASE IN CHOLYCYSTOKININ SECRETION

  44. 4. PIGMENT STONES OCCUR WITH HEMOLYSIS( HEREDITARY SPHEROCYTOSIS, SICKLE CELL ANEMIA, THALASSEMIA, MALARIA) WHERE BILIRUBIN PRODUCTION WILL INCREASE. PIGMENT STONES ALSO INCEASE WITH BENIGN AND MALIGNANT STRICTURES AND WITH PARASITE INFESTATION OF THE BILIARY DUCTS( ASCARIS LUMBRICOIDES, CHLONORCHIS SINENSIS)

  45. INCIDENCE OF GALL STONES FAT, FERTILE, FLATULENT, FEMALE, FIFTY- IS THE USUAL SUFFERER OF GALL STONES IT CAN OCCUR AT ANY AGE AND IN BOTH SEXES TOW THIRD ARE ASYMPTOMATIC SAINT’S TRIAD- GALL STONES DIVERTICULOSIS HIATUS HERNIA

  46. COMPLICATIONS OF GALL STONES 1.IN THE GB- SILENT( NO INDICATION FOR OPERATION) CH CHOLECYSTITIS AC CHOLECYSTITIS GANGRENE PERFORATION EMPYEMA MUCOCELE CARCINOMA 2. IN THE BILE DUCTS- OBSTRUCTIVE JAUNDICE CHOLANGITIS ACUTE PANCREATITIS 3. IN THE INTESTINE- ACUTE INTESTINAL OBSTRUCTION (GALL STONE ILEUS)

  47. CHRONIC CALCULOUS CHOLECYSTITIS THICK, FIBROTIC WALL, BACTERIA ISOLATED IN LESS THAN 30% OF CASES FROM THE BILE AND SUGGESTS A CHEMICAL IRRITANTS IN THE BILE RATHER THAN BACTERIAL AS A CAUSE IN THE OTHER CASES

  48. CHRONIC CHOLECYSTITIS